Hallux Valgus – 6 Interesting Facts, Symptoms, Causes, Diagnosis and Treatment

6 Interesting Facts of Hallux Valgus

  1. Hallux valgus is a common progressive forefoot deformity consisting of lateral deviation of the hallux (big toe) at the metatarsophalangeal joint accompanied by medial deviation of the first metatarsal (metatarsus primus varus)
    • Great toe angulates away from midline and toward other toes
    • Bony eminence at medial aspect of first metatarsal head is referred to as a bunion
  2. Heredity and constricting footwear are considered major contributing factors
  3. Deformity may be asymptomatic or result in foot pain and dysfunction
    • Pain typically located over bunion or beneath the lesser metatarsophalangeal joints
  4. Diagnosis is based on clinical history, physical examination, and radiographs
    • Radiographs assist in deformity assessment and treatment planning
  5. Treatment consists of conservative and surgical measures
    • Conservative treatment is the preferable first option and may improve symptoms and function, but it does not correct the deformity
    • Many surgical procedure options are available; success depends on choosing best technique for a given deformity
  6. After appropriate surgical intervention, most patients are satisfied and have good clinical result
  • Hallux valgus is a common progressive forefoot deformity consisting of lateral deviation of the hallux (big toe) at the metatarsophalangeal joint accompanied by medial deviation of the first metatarsal (metatarsus primus varus)
    • Great toe angulates away from midline toward other toes
  • With progression, the first metatarsal head slides medially off the sesamoids
    • Bony eminence at the medial aspect of the first metatarsal head is referred to as a bunion
      • Thickening or inflammation of the bursa overlying the first metatarsal head can accentuate this medial eminence

Clinical Presentation

History

  • Clinical history of Hallux Valgus includes duration of symptoms, activity modification, usual footwear choices, previous interventions, history of foot trauma or arch collapse, and familial inheritance
  • Pain may be present
    • Patients may complain of great toe “pointing inward” (ie, laterally) toward other toes and causing:
      • Difficulty fitting desired footwear owing to deformity
      • Cosmetic concerns
    • Symptoms can include:
      • Pain
        • First metatarsophalangeal joint pain, soreness, or stiffness
          • Inflammation of overlying bursa can cause pain over medial eminence
        • Pain may be located beneath the lesser metatarsophalangeal joints
          • Malfunction of a given metatarsophalangeal joint may produce pain at another metatarsophalangeal joint
        • Pain/pressure under second or third metatarsals can result from transfer metatarsalgia (pain at different ray than mechanically impaired ray)
        • Typically worse when wearing tight shoes or high heels and with weight bearing
      • Burning or numbness owing to compression of digital nerve

Physical examination

  • Both bare feet examined in sitting and standing positions
    • Observation
      • Gait may be antalgic or externally rotated
      • Alignment
        • Medial deviation of first metatarsal and lateral deviation of hallux
        • Pronation of hallux (nail faces medially)
      • Inflammation and edema over medial eminence; ulceration may be noted
      • Forefoot may be wide
      • Deformities of lesser toes, midfoot, or hindfoot
        • Pressure of the great toe against the second toe may lead to malalignment, subluxation, or dislocation of the second metatarsophalangeal joint
      • Thickened skin over metatarsophalangeal joint and/or plantar surface (callus)
  • Palpation
    • Focal tenderness to palpation over medial eminence
      • Tenderness over dorsal hallux metatarsophalangeal joint may indicate arthritic component
    • Tender plantar calluses indicate transfer lesions under the lesser metatarsophalangeal joints
      • Owing to shift in load-bearing capacity from first ray (metatarsal, sesamoids, and hallux) across to lesser toes
  • Range of motion
    • Decreased mobility of metatarsophalangeal joint
      • Active and passive range of motion is assessed
        • With neutral position as recorded 0°, average passive dorsiflexion is 67°, and plantar flexion is 20° in adults aged over 45 years 
      • Motion evaluated in reduced and nonreduced positions
        • Manual attempt to reduce deformity is made while gently dorsiflexing and plantar flexing the first metatarsophalangeal joint; can determine degree of correction that may be achieved 
          • If motion is increased in reduced position, it may suggest contracture of lateral soft tissues
          • If motion is decreased in reduced position, it may indicate a change in the articular surface angle
          • If motion is restricted in reduced or nonreduced position, there may be degenerative change
        • Pain or crepitus may indicate degenerative changes
      • Toe pronation on extension can indicate intrinsic malalignment
    • Hypermobility of first ray
      • Increased laxity of the first metatarsocuneiform joint may contribute to deformity 
        • Examination performed with ankle in neutral dorsiflexion
        • Second metatarsal head is stabilized with 1 hand while first metatarsal head is moved dorsomedially then plantar-laterally to gauge degree of hypermobility; compared with contralateral side
          • Grading may be described as mild, moderate, substantial mobility, and hypermobile 
          • Technique has consistent intrarater reliability, but little clinical objectivity comparing magnitudes among examiners 
      • The second metatarsophalangeal joint should also be examined
    • Ankle, subtalar, and transverse tarsal joints
      • Hindfoot deformity may contribute to development of forefoot issues
        • Ankle joint: assessed by dorsiflexing and plantar flexing the foot at level of ankle joint
          • Allows sagittal plane motion of 20° of dorsiflexion to 50° of plantar flexion along an axis running between tips of the malleoli; marked variability between individuals 
        • Subtalar joint: assessed by holding heel with palm of 1 hand, fingers on posterior heel; with other hand, the foot is inverted and everted
          • Range of motion approximately 30° of inversion and 15° of eversion; magnitude variable between persons 
        • Transverse tarsal joint: evaluated by holding heel with palm of 1 hand, fingers on posterior heel; with other hand, the foot is abducted and adducted
          • Normal motion is approximately 20° of adduction and 10° of abduction 
  • Peripheral vascular perfusion and motor/sensory function are evaluated
    • Vascular occlusive disease can preclude surgical options
    • Numbness or paresthesia over the dorsomedial distal phalanx can result from compression/irritation to dorsal cutaneous nerve overlying the bursa 

Causes

  • Cause of hallux valgus is uncertain but likely multifactorial, including: 
    • Intrinsic factors
      • Genetic variations that result in altered biomechanics
      • Sex (more common in females than in males)
      • Ligamentous laxity
      • Other foot deformities (eg, pes planus, pronated hindfoot, metatarsus primus varus)
      • Age (prevalence increases with age)
      • Neuromuscular disorders (eg, cerebral palsy, stroke)
    • Extrinsic factors
      • Footwear (high heels, narrow toe box)
        • High heels increase forefoot loading; may exacerbate deformity 
      • Excess weight bearing
  • Progressive deformity involves several steps, in concert with predisposing factors; often a parallel process rather than sequential 
    • Begins with lateral deviation of great toe and medial deviation of first metatarsal
    • Later stages involve progressive subluxation of the first metatarsophalangeal joint
    • Bursa over joint thickens over time owing to pressure of footwear on medial eminence 

What increases the risk of Hallux Valgus?

Age
  • Prevalence increases with age
    • Age of onset varies widely
Sex
  • Affects women more commonly than men
    • May be associated with more narrow, high-heeled footwear
Genetics
  • Familial association
    • 83% of patients have a positive family history of hallux valgus deformities
Other risk factors/associations
  • Tends to be bilateral
  • Other possible associations include:
    • Long first metatarsal
    • Oval or curved metatarsophalangeal joint articular surface
    • Increased first ray mobility
    • Achilles tendon tightness
    • Pes planus
    • Plantar gapping of first metatarsal cuneiform joint

How is Hallux Valgus diagnosed?

Primary diagnostic tools

  • Diagnosis is by clinical history, physical examination, and radiography 
  • Obtain dorsoplantar and lateral weight-bearing radiographs for all patients with suspected hallux valgus 
  • Additional radiographic views may be necessary to assess deformity and assist in treatment planning, but advanced imaging is typically not necessary

Imaging

  • Weight-bearing dorsoplantar and lateral radiographs of the feet
    • 2 important angles are assessed to determine radiologic severity
      • Hallux valgus angle
        • Angle between long axes of proximal phalanx and first metatarsal
      • Intermetatarsal angle: 
        • Angle between long axes of first and second metatarsals
    • Other angles that may be useful in treatment planning include:
      • Distal metatarsal articular angle (10°-15°) 
      • Hallux interphalangeus angle (normal angle less than 10°) 
  • Severity of hallux valgus can be classified based on standing anteroposterior radiographs 
    • Normal
      • Hallux valgus angle: less than 15°
      • Intermetatarsal angle: less than 9°
      • Subluxation of lateral sesamoid on anteroposterior view: none
    • Mild
      • Hallux valgus angle: less than 20°
      • Intermetatarsal angle: 11° or less
      • Lateral sesamoid subluxation: less than 50%
    • Moderate
      • Hallux valgus angle: 20° to 40°
      • Intermetatarsal angle: less than 16°
      • Lateral sesamoid subluxation: 50% to 75%
    • Severe
      • Hallux valgus angle: greater than 40°
      • Intermetatarsal angle: 16° or greater
      • Lateral sesamoid subluxation: greater than 75%
  • Other radiographic observations that can be useful in guiding treatment include: 
    • Various other angular and positional relationships (eg, distal metatarsal articular angle, interphalangeus angle)
    • Metatarsal head shape
      • More convex articular surface is more prone to hallux valgus deformity
    • Position of sesamoids relative to metatarsal head
      • May demonstrate severity of deformity, degree of pronation, and pathologic changes in sesamoids
    • Gapping of plantar aspect of first metatarsocuneiform joint
    • Arthrosis of metatarsophalangeal joint
    • Metatarsus adductus
    • Presence of intermetatarsal facet or os intermetatarseum
  • Additional radiographs can include nonstanding lateral oblique views and axial sesamoid views 
    • Axial sesamoid view may aid in determining extent of intrinsic malalignment
    • Can be useful preoperatively

Differential Diagnosis

Most common

  • Hallux rigidus
    • Osteoarthritis of the first metatarsophalangeal joint
    • As with hallux valgus, symptoms include pain, stiffness, and swelling at first metatarsophalangeal joint
    • Differentiated by tender bump (bunion); if present, typically located on dorsal aspect of metatarsophalangeal joint
      • Examination may show limited and painful range of motion, especially dorsiflexion; crepitus may be noted
    • Diagnosis based on physical examination and radiographs (eg, sclerosis, subchondral cysts, joint space narrowing, osteophytes, dorsal bone spur)
  • Gout
    • Gout is a common inflammatory arthritis caused by deposition of monosodium urate crystals
    • As with hallux valgus, symptoms include pain, stiffness, and swelling at first metatarsophalangeal joint
    • Differentiated by relatively acute onset of pain, redness, and swelling in joint
    • Diagnosis based on history, physical examination, and laboratory testing
      • Definitive diagnosis by joint aspiration
        • Diagnostic gold standard for gout is presence of negatively birefringent monosodium urate crystals in a synovial fluid sample viewed under polarized light microscopy 
      • Important to differentiate from septic joint
  • Rheumatoid arthritis (Related: Rheumatoid Arthritis)
    • An autoimmune disease; immune complexes within synovial membrane cause inflammatory response leading to synovial thickening and joint destruction
      • Frequently affects joints of the feet; hallux valgus is predominant foot deformity 
    • Similar symptoms include pain, swelling, and stiffness; resulting deformities include bunions, claw toes, and metatarsalgia
    • Affects multiple joints; typically both feet and similar joints involved (symmetrical)
    • Diagnosis based on clinical criteria, laboratory results (eg, levels of rheumatoid factor, anticyclic citrullinated peptide; antinuclear antibody assays), and imaging features (eg, erosions, joint space narrowing)
  • Septic arthritis
    • Infection within joint space; typically bacterial
      • Important to consider in patients with acute joint disease
      • Can lead to rapid, irreversible joint destruction; associated with significant morbidity and potentially fatal
    • Similarly, presents with joint pain, redness, and swelling
    • Differentiated by relatively acute symptom onset; fever may be present
    • Diagnosis suggested by clinical history, physical examination, and laboratory testing (eg, WBC count, erythrocyte sedimentation rate, C-reactive protein levels)
      • Joint aspiration with synovial fluid analysis and culture is essential for the diagnosis 

Treatment Goals

  • Relieve pain
  • Prevent progression
  • Accommodate existing deformity
  • Improve function
  • Restore articular anatomy (requires surgical correction)

Disposition

Recommendations for specialist referral

  • Refer to specialist (eg, orthopedist, podiatrist) for possible surgical intervention when conservative measures fail 

Treatment Options

Treatment consists of conservative (nonsurgical) and surgical measures

Conservative treatment

  • Preferable as first option
    • Primary therapy in juvenile hallux valgus, elderly patients, and those with severe neuropathy, vascular compromise, or other comorbidity in whom surgery is contraindicated 
  • Does not correct the deformity but may improve symptoms and function 
  • Modalities include: 
    • Analgesics (eg, NSAIDs)
    • Footwear choice: wide toe box, soft shoe with sufficiently padded insole, avoidance of high heels
    • Physical therapy
      • May be useful alone for mild hallux valgus, or in addition to other conservative treatments
      • Can include gait training, exercise, manual therapy, taping, and orthosis
    • Activity modification
    • Orthotics (shoe inserts)
      • May provide symptomatic relief in some patients
      • Can include medial posting (to control pronation), metatarsal pad/bar (for transfer lesions), bunion flare, and extra-deep shoe with oblique toe box (accommodative) 
      • A Cochrane review found orthoses reduced foot pain after 6 months (compared with no treatment) but did not reduce foot pain after 6 or 12 months compared with surgery in patients younger than 60 years 
    • Toe spacers
      • Wearing insole with toe separator may decrease pain intensity; not effective in improving great toe angles

Surgical

  • Symptomatic patients in whom conservative therapy fails are candidates for surgical correction 
    • Continued pain and dysfunction (disruption of lifestyle/activities) are indications for surgical consideration
    • Not recommended for cosmetic repair in asymptomatic patients owing to inherent surgical risks 
    • Principal contraindication is arterial occlusive disease; indistinct pedal pulses must be evaluated further 
  • Over 150 techniques have been described
    • Diversity of surgeries partially owing to the multiple factors causing hallux valgus 
    • A Cochrane review concluded no technique has been shown to be superior 
    • Must be individualized for each patient
  • Surgical success depends on choosing best procedure for individual given deformity 
    • Guided by careful evaluation of conventional radiographs
      • Various factors considered, including hallux valgus angle, intermetatarsal angle, distal metatarsophalangeal joint congruity, and presence of arthritis 
    • Surgeon’s expertise and experience are factors 
    • Management of patient expectations is important; ability to wear desired footwear or perform high-impact activity should be tempered 
      • Up to 41% of patients are not able to return to desired footwear choices 
    • Options include various procedure categories, alone or in combination: 
      • Distal soft-tissue reconstruction
      • First metatarsal osteotomies (distal and/or proximal)
      • Proximal phalanx osteotomies
      • Arthrodesis (fusion)
      • Excisional arthroplasty
  • Postoperative physical therapy and gait training may aid in improving function after surgery 

Nondrug and supportive care

  • Patient education
    • Inform patients about progressive nature of disease process as well as treatment options and realistic goals

Special populations

  • Juvenile (pediatric) hallux valgus
    • Relatively uncommon in children
    • Usually asymptomatic in pediatric population; typically comes to medical attention owing to cosmetic appearance of bunion
    • Radiographs, in addition to showing underlying deformity, provide assessment of epiphyseal plates to aid in management decisions
    • Treatment is typically conservative until after skeletal maturity
      • Surgical correction associated with high recurrence rate and variable clinical outcomes; higher risk of overcorrection
        • Delay is preferred until skeletal maturity unless significant pain and deformity interfere with daily living
        • Epiphyseal injury may result in growth disturbance

Complications

  • Complications of hallux valgus include:
    • Osteoarthritis of first metatarsophalangeal joint
    • Deformation and pain in other digits forced upward resulting in hammer or claw toes 
    • Lateral metatarsalgia owing to pressure transfer from great toe to lateral metatarsal region 
  • Surgical complications include: 
    • Recurrence (foremost complication)
    • Nonunion
    • Avascular necrosis
    • Hallux varus
    • Transfer metatarsalgia
    • Neuromas
    • Hyperesthesia
    • Degenerative arthritis
    • Unmet patient expectations

Prognosis

  • Left untreated, condition has uncertain prognosis
    • Deformity and symptom progression may be rapid in some people whereas others remain asymptomatic
  • After appropriate surgical intervention, 85% of patients are satisfied and have good clinical result 
    • 10% are less satisfied, with suboptimal outcome; 5% have poor results 
    • Relief of pain is primary objective, but ability to wear smaller/narrower shoes is a frequent goal
      • Up to 41% of patients are unable to return to desired shoe choices 

Prevention

  • No prevention strategy known; cause is likely multifactorial, involving interplay between intrinsic and extrinsic factors

References

Coughlin MJ et al: Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 28(7):759-77, 2007 Cross Reference

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